Controversies in Chest Compressions & Airway Management During CPR. Bob Berg
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1 Controversies in Chest Compressions & Airway Management During CPR Bob Berg
2 No Financial Conflicts of Interest Employment: University of Pennsylvania AHA Volunteer AHA GWTG-R & Systems of Care committees Past Chair, GWTG-R Committee Past Chair, BLS Committee Past Chair, PALS Committee 2015 ILCOR BLS Evidence Evaluation 2015 AHA Systems of Care Guidelines Grants: NICHD, NHLBI Intellectual Conflicts of Interest >25 yrs of Cardiac Arrest & CPR Research
3 Introduction Chest compressions Hands-only CPR Physiologic-directed/patient-centered CPR Tracheal Intubation during in-hospital CPR
4 Closed-chest massage Kouwenhoven, Jude, Knickerbocker, JAMA 1960 While studying defibrillation in small dogs Ao pressure increased with paddles Adequate circulation for 30 min of CC-only CPR 20 patients: asphyxia in peri-op setting 20/20 survived the cardiac arrest 14/20 long-term survivors
5 Arterial Blood Pressure during CPR Jude, JAMA 1961
6 CCC-CPR vs Standard CPR for VF Hr Survival in 169 swine in 6 studies Hour Neurologically Normal Survival Percent 80% 40% 20% 0% 73% 70% 7% CCC-CPR Std-CPR No CPR University of Arizona Sarver Heart Center CPR Research Group
7 Why isn t Rescue Breathing necessary initially for VF? Excellent SaO 2 at time of VF O 2 reservoir: lungs Rescue breathing is life-saving for Gasping ventilation asphyxia cardiac arrests 39-55% of prehospital arrests Clark AEM 1992 Bang Resus 2003 Bobrow Circ 2008 Compression-induced ventilation
8 Survival by Layperson Bystander CPR Type Survival to Hospital Discharge 25% 20% 15% 10% 5% 0% Adj OR 1.59 (95% CI: 1.08, 2.35) vs conventional CPR 5.2% 150/2900 No CPR 7.8% 52/666 Conventional CPR 13.3% 113/849 Handsonly CPR Bobrow, Spaite, Berg et al. JAMA 2010
9 Dissemination of CC-only CPR and Survival after adult OHCA 816,835 OHCAs No CPR 57.1% CC-only CPR 30.6% Conventional CPR 12.3% Iwami, Circulation 2015
10 Dissemination of CC-only CPR and Survival after adult OHCA CC-CPR (n=249,970) Conventional CPR (n=100,469) No CPR (n=465,946) P Prehospital ROSC (6.3) 7982 (7.9) (5.2) < month survival (4.3) 5717 (5.7) (3.6) <0.001 CPC 1 or (1.9) 2690 (2.7) 5762 (1.2) <0.001 Iwami, Circulation 2015
11 Dissemination of CC-only CPR and Survival after adult OHCA Iwami, Circulation 2015
12 Dispatcher-assisted CPR RCTs Hupfl, Lancet 2010
13 November 2013 High quality CPR is the primary component influencing survival Monitor CPR, but what targets?
14 Measure CC Rate, Depth, and Leaning
15 CPR QUALITY MAKES A DIFFERENCE Sutton, Resuscitation 2014
16 Do we have the right CPR targets to monitor? Rescuer-centric goals (2 inches/5 cm) versus Patient-centric hemodynamic goals
17 Coronary Perfusion Pressure Critically Important for Successful CPR CoPP >20 mmhg; AoD >30 mmhg Sanders, CCM 1984 Michael, Circ 1984 Kern, Resus 1988 Crile, Expt Med 1906
18 Coronary Perfusion Pressure during CPR Adult OHCA Paradis, JAMA 1990
19 Blood Pressure Guided CPR Improve Outcomes In Swine Cardiac Arrest Model BP-Guided Care CC depth titrated to SBP > 100 mmhg If CPP < 20 mmhg, Epi 0.02 mg/kg qmin prn x 2, then vasopressin 0.4 U/kg. Repeat sequence after 2 min prn 5/8 (63%) favorable neurologic outcome 7 min untreated VF Standard Guideline Care (provider-centric) Standard CC depth Epi 0.02 mg/kg every 4 minute 0/8 (0%) favorable neurologic outcome Sutton AJRCCM 2014, Sutton Resus 2013; Friess CCM 2013; Naim CCM 2016; Morgan Resus 2017
20 PICqCPR Relationship of Arterial DBP (from start of CPR until up to 10 minutes) with Survival Outcomes Berg, Sutton, Nadkarni & CPCCRN investigators PAS Abstract 2017
21 Index CPR Events 1 min N = 164 ROSC > 20 min 112 (68%) Survival to discharge 77 (47%) Favorable neuro outcome 70 (43%) Mean DBP 25 mmhg (infants) or 30 mmhg Children N = 101 (62%) ROSC > 20 min 75 (74%) Survival to discharge 55 (54%) Favorable neuro outcome 49 (49%) Mean DBP < 25mmHg (infants) <30 mmhg (children) N = 63 (39%) ROSC > 20 min 37 (59%) Survival to discharge 22 (35%) Favorable neuro outcome 21 (33%)
22 Association of mean DBP 25/30mmHg with Outcomes (N=163) arr (95%CI) P-value ROSC 1.2 (1.0, 1.6) 0.07 Surv to d/c 1.7 (1.2, 2.6) Survive with Favorable Neuro 1.6 (1.1, 2.5) 0.01
23 Waveform Capnography During CPR Neumar 1/21/ American Heart Association. All rights reserved.
24 End-Tidal CO 2 is Proportional to Cardiac Output During Swine CPR 10 cmh 2 0 Idris, Ann Emerg Med 1994 Neumar 1/21/17 Normal Cardiac Index ml/min/m 2
25 ETCO2 in adult OHCA Sanders, JAMA 1989 Average end tidal CO2
26 End-Tidal CO 2 Prognostication during CPR Levine NEJM 1998
27 Goal-Directed CPR? ACLS 2015 Focused Update Although no clinical study has examined whether titrating resuscitative efforts to physiologic parameters during CPR improves outcome, it may be reasonable to use physiologic parameters (quantitative waveform capnography, arterial diastolic pressure) when feasible to monitor and optimize CPR quality, guide vasopressor therapy, and detect ROSC. (Class IIb, LOE C-EO) Neumar 1/21/17 1/21/17
28 Potential CPR Physiologic Goals Parameter Futility Goal References Coronary Perfusion Pressure <15 mmhg >25 mmhg Paradis 1990 Kern 1988 Arterial Relaxation Pressure <20 mmhg >30 mmhg Paradis 1990 Berg abstr 2017 End-Tidal CO 2 (PetCO 2 ) <10 mmhg >20 mmhg Levine 1998 Modified from Neumar 1/21/17
29 Tracheal Intubation during Pediatric CPR Hypothesis: TracheaI intubation during cardiac arrest would be associated with improved outcome 2294 time-dependent propensity matched IHCAs Survival to Hospital Discharge 36% TI vs 41% not TI during CPR arr 0.89 (95%CI ), P=0.03 Mechanism:?interruptions, CPR quality, bag-mask often adequate? Message: TI during CPR is high risk Andersen, JAMA 2016
30 Tracheal Intubation during Adult CPR 86,628 time-dependent propensity matched IHCAs Survival to Hospital Discharge 16.3% TI vs 19.4% not TI arr 0.84 (95%CI ), P<0.001 Favorable Neuro (CPC 1 or 2): arr 0.97 (95%CI ) Although the study design does not eliminate potential for confounding, these findings do not support early tracheal intubation for in-hospital cardiac arrest Andersen, JAMA 2016
31 Conclusion Chest compressions Hands-only CPR can be life-saving Physiologic-directed/patient-centered CPR is the way of the future Tracheal Intubation during CPR is a high risk intervention
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